Pediatric ultrasound screening decreased number of unnecessary operative procedures in developmental hip dysplasia treatment

Christian Tschauner, MD

This paper reflects the effect of a general ultrasound screening program under real life conditions in Germany. Starting in 1996, free access to an ultrasound screening program within the first 6 weeks of life was offered to the German population. Ultrasound screening is performed by methodically trained orthopaedic surgeons and pediatricians using the standardized Graf method of hip ultrasound; surgical treatment is done in specialized pediatric orthopaedic units. The study used the case-control approach and documented an effectiveness of 52% of ultrasound screening to prevent first operative procedures for developmental dysplasia of the hip (DDH). This was achieved between 1996 and 2001 under real life conditions including a variety of practical shortcomings, including insufficient sonographic practice and suboptimal treatment.

This positive experience from Germany is shared by data of the Austrian Ministry of Public Health and of specialized tertiary pediatric orthopaedic referral centers regarding the decrease of the necessity for surgical treatment (Tschauner et al) and the cost-effectiveness (Thaler et al) of ultrasound screening under the conditions of a public health approach: The rate of 1 to 2 per 10,000 live births in Austria is the lowest one ever published (Farr et al). Additionally, Thallinger and Grill (personal communication) could document a decrease of functional bracing for DDH from about 12 % before sonography to less than 3 % with sonographic screening.

The key feature of this progress is the young age at definitive pathomorphological diagnosis, which is made possible by Graf`s strictly standardized sonographic examination technique, which needs teaching in structured teaching courses. Young age (equal to 6 weeks to 8 weeks at initial treatment) means an early stage of a developing pathomorphology and respectively a short, easy and safe therapeutic way back to normomorphology. One special highlight of Graf´s method is the visualization of an at-risk-morphology or “pre-luxation-stage” that is regularly clinically silent: without early sonographic diagnosis, this pre-luxation stage would remain untreated and would develop a progressive secondary decentering that in the past was regarded as a missed case.

The Central European experience proved an effective sonographic screening approach for DDH with a resulting early definitive pathomorphological diagnosis (Graf classification) and a consequent sonomorphology-based treatment algorithm. Sonographic screening using Graf´s technique is the adequate tool for early diagnosis, which was already required by Tönnis et al. Tönnis’ vision from 1987 has become reality in 2012.

References:

• Farr S, Grill F, Muller D. When is the optimal time for hip ultrasound screening? Orthopade. 2008;37(18483720):534-536.
• Thaler M, Biedermann R, Lair J, et al. Cost-effectiveness of universal ultrasound screening compared with clinical examination alone in the diagnosis and treatment of neonatal hip dysplasia in Austria. J Bone Joint Surg Br. 2011;93:1126-1130.
• Tönnis D. Congenital dysplasia and dislocation of the hip in children and adults. Berlin: Springer; 1987.
• Tschauner C, Fürntrath F, Saba Y, et al. Developmental dysplasia of the hip: impact of sonographic newborn hip screening on the outcome of early treated decentered hip joints - a single center retrospective comparative cohort study based on Graf`s method of hip ultrasonography. J Child Orthop. 2011;5(6):415-424.